Differential Diagnosis of Addictive Sexual Disorders
The most common types of excessive sexual behaviors can be classified into three Axis I categories: paraphilias, impulse control disorder Not Otherwise Specified (NOS), or sexual disorder NOS. The paraphilias are characterized by recurrent, intense sexual urges, fantasies, or behaviors that involve unusual objects (such as animals or inanimate objects), activities or situations (for example, involving nonconsenting persons, including children, or causing humiliation or suffering). For some individuals, paraphilic fantasies or stimuli are essential for erotic arousal and are always part of sexual activity; in other cases, the paraphilic preferences occur only episodically. In contrast to sexual dysfunctions, which are associated with decreases in sexual functioning, the paraphilias are commonly associated with increases in sexual activity, often with compulsive and/or impulsive features.

While some cases of sexual excess represent impulse-control disorders, many others cannot be classified as either paraphilias or impulse-control disorders. If they cause distress to the person, they can be diagnosed as Sexual Disorder NOS. Many of these cases can be considered as addictive disorders.

The essential features of all substance use disorders are behavioral, consisting of: (1) loss of control
(2) preoccupation, and
(3) continuation despite adverse consequences.

These same criteria can be applied to excessive behaviors such as excessive sexual behaviors, compulsive overeating, and pathological gambling. This analysis suggests that an addiction-sensitive treatment model might be effective in treating disorders of excess involving sex, food, and gambling.

(4) Other psychiatric disorders can also be associated with sexual excesses.

In addition, Axis II characterological disorders (eg, antisocial personality disorder, narcissistic personality disorder) are often contributory, or may be the primary cause of paraphiliac or nonparaphiliac excessive sexual behavior. The frequent and infrequent Diagnostic and Statistical Manual of Mental Disorders Axis I diagnoses associated with sexual excesses are presented in (PP4:16,17).5

The word "excessive," as used in this article, does not specify a particular quantity, frequency, or type of sexual behavior. Rather, what makes these behaviors addictive disorders is that the patient has expended much time and mental energy in connection with the behavior, and has incurred distressing life consequences as a result of the behavior yet has been unable to stop.

Among 1,000 patients admitted for inpatient treatment of addictive sexual disorders, Carnes2 discerned 10 patterns of behavior, summarized in (PP4:18). Five of the categories covered in (PP4:18) constitute specific DSM-IV paraphilias: voyeuristic sex, exhibitionistic sex, pain exchange (sexual sadism, sexual masochism), some types of intrusive sex (frotteurism), and exploitative sex (pedophilia).

Four of the remaining categories may be correlated with paraphilias as follows:

1. fantasy sex may be associated with paraphiliac urges not acted upon;
2. anonymous sex may be used to permit expression of paraphiliac behavior with decreased risk of consequences; and
3. paying for sex and
4. trading sex are means by which a partner who may permit paraphiliac activities may be purchased.

Whether the specific pattern is diagnosed as paraphiliac or nonparaphiliac, its compulsive nature often leads to a failure of traditional psychotherapeutic techniques to cure it, and success with addiction-based approaches.

Gender Differences
Significant gender differences have been observed in the prevalence of various patterns of addictive sexual behaviors.

(6) Men tend to engage in behavioral excesses that objectify their partners and require little emotional involvement (voyeuristic sex, paying for sex, anonymous sex, and exploitative sex). A trend toward emotional isolation is clear. Women tend to be excessive in behaviors that distort power either by gaining control over others or being a victim (fantasy sex, seductive role sex, trading sex, and pain exchange).

Women sex addicts use sex for power, control, and attention. 6,7

Case 1: A 34-year-old woman from a rigidly religious family married an alcoholic. After 2 years of marriage, she became involved in the first of many extramarital affairs. To avoid detection by her husband, she withdrew from him emotionally and neglected the marital relationship. She recognized that she was not spending enough time with her children, but felt powerless to change. Despite feelings of guilt, she did not seek help until she cheated on her new lover. Slide #PP4:18